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Medicare preserves local coverage determination for CCTA

Radiology Administrator's Compliance and Reimbursement Insider, July 1, 2008

There’s good news for patients with heart disease. CMS has decided not to restrict reimbursement for cardiac CT angiography (CCTA), instead leaving the decision about coverage in the hands of local fiscal intermediaries.

Specifically, CMS chose to make no change to section 220.1 of the National Coverage Determination Manual, “Computed Tomography” (Pub. 100-3, 220.1). CMS decided that no national coverage determination (NCD) on the use of CCTA for coronary artery disease is appropriate at this time, and that coverage should be determined by local contractors through the local coverage determination process or case-by-case adjudication.

We’ll tell you about the CCTA ruling, and, as an added bonus, offer some ways to prevent common coding errors on billing for cardiology procedures.

Background on CCTA

CCTA is a noninvasive technology that produces detailed coronary-artery images, says William Shea, MD, vice president of 3D Imaging Services, NightHawk Radiology Holdings, Inc., in Coeur d’Alene, ID.

CMS says the increased use of CCTA stems from advances in the technology and rapid diffusion of the machines outside hospital settings. The initial single slice CT machines produced poor-quality images. In the late 1990s, four-slice CT machines were introduced, with 16-slice and 64-slice CT machines following shortly afterward. Image quality and performance reportedly increased with each model.

Although CMS noted that CCTA may reduce the need for invasive coronary angiography for certain patients, critics point to the lack of evidence on CCTA outcomes and the limitations of the technology, including uninterpretable/unassessable image segments.

This decision focuses only on the use of CCTA for the evaluation of coronary arteries in patients with chest pain, says Shea.

Imaging performed on patients without chest pain would be considered screening and is not an available benefit in the Medicare program, he explains.

CMS found, in summary, that there is uncertainty regarding any potential health benefits or patient management alterations from including CCTA in the diagnostic workup of patients who may have coronary artery disease. According to CMS:

No adequately powered study has established that improved health outcomes can be causally attributed to coronary CTA for any well-defined clinical indication, and the body of evidence is of overall limited quality and limited applicability to Medicare patients with typical comorbidities in community practice.

CMS said that although comments did not dispel the uncertainty of the test’s clinical utility, they strongly favored maintaining the local coverage policies for CCTA.

Industry expresses general relief at ruling

“I am happy that CMS took the time to evaluate the literature and listen to the American College of Radiology, as well as other groups and political bodies,” says Shea. “CCTA is a proven diagnostic tool that can spot disease more quickly, more reliably and, ultimately, at less cost.”

Others are more reticent. “It’s difficult to make a sweeping statement on the ruling,” says Larry W. Balmer, CCP, compliance and HIPAA privacy and security officer at Radiology, Inc., in Mishawaka, IN. “Nothing has essentially changed, and coverage is dependent on each carrier.” It’s possible that a uniform NCD can offer more clarity, he notes. Shea agrees that an NCD could provide greater clarity, but only if it were more inclusive.

Until now, physicians were reluctant to use the exam due to reimbursement concerns, Shea says. He predicts the CMS coverage ruling will give the industry greater confidence in the procedure and spur more hospitals to begin providing CCTA procedures. He also predicts the results will reduce the need for patient hospitalization, and, in turn, reduce healthcare costs.

As a substitute for invasive cardiac catheterization, CCTA would cost about $800, compared with $4,000 or more, Shea adds.

The proposed national policy, released in December 2007, would have limited reimbursement for CCTA to “symptomatic patients with chronic angina at intermediate risk of coronary artery disease and symptomatic patients with unstable angina at low risk of short-term death or intermediate risk of [coronary artery disease].” An NCD would have set aside local policies to authorize payment for the procedure in all 50 states.

If the proposed NCD had been approved, only procedures performed in CMS-approved clinical trials would have been reimbursed by Medicare. Such a ruling would have denied CCTA reimbursement to most of the estimated 2,000 facilities equipped with multislice scanners until the end of the trials. With Medicare leading the way, private insurers could also be expected to reduce or halt CCTA reimbursement.

Additional changes possible

Despite the lack of an NCD, CMS encouraged future research on the benefits of CCTA. Reconsideration of CCTA
reimbursement depends on peer-reviewed publication and critical evaluation of convincing new evidence, CMS noted.

Essentially, CMS has thrown the ball back into the industry’s court for further research and studies, says Shea.

CMS also stated that current guidelines do not provide sufficient guidance to patients and providers as to the appropriate inclusion of CCTA into the diagnostic milieu in the workup of chest pain. CMS expressed concern that providers are using CCTA as an additional test added to cardiac stress testing and nuclear imaging, rather than thoughtfully considering the appropriate mix of these tests. Some professionals agree.

Insider sources

Larry W. Balmer, CCP, compliance/HIPAA privacy and security officer, Radiology, Inc., 620 Edison, Suite 110, Mishawaka, IN 46545; 574/258-1100, Ext. 284; lbalmer@rad-inc.com.

Jackie Miller, RHIA, CPC, senior consultant, Coding Strategies, Inc., 5041 Dallas Highway, Suite 606, Powder Springs, GA 30127, 770/445-5566; jackie.miller@codingstrategies.com.

William Shea, MD, vice president, 3D Imaging Services, NightHawk Radiology Holdings, Inc., U.S. Corporate Office, 250 Northwest Boulevard, Suite 202, Coeur d’Alene, ID 83814, 866/400-4295; bshea@nighthawkrad.net.


Avoid five common billing mistakes in noninvasive cardiology procedures

The following are some common mistakes in billing for cardiology procedures, according to billing expert Jackie Miller, RHIA, CPC, senior consultant at Coding Strategies, Inc., in Powder Springs, GA.

Reporting more than one myocardial perfusion scan. Myocardial perfusion imaging (MPI) frequently involves performance of two or more scans. Some protocols involve scanning on two days. Regardless of the number of scans or the number of days, only one MPI code should be reported. MPI studies that include multiple scans should be reported with code 78461 for planar studies or 78465 for SPECT studies. Additional codes can be reported for wall motion (78478) and ejection fraction (78480), if performed and documented. Remember, if you are billing for a SPECT MPI, the report should indicate that SPECT imaging was performed.

Incorrectly reporting CCTA for heart structure. Codes 0145T, 0148T, and 0149T include the study of heart structure and morphology. These are detailed exams of cardiac anatomy that are typically performed in preparation for catheter ablation (e.g., pulmonary vein isolation) or insertion of a biventricular pacemaker or implantable cardioverter-defibrillator. A heart structure exam code should not be reported when the physician documents a brief description of gross cardiac anatomy as part of a CTA study of the coronary arteries. In that situation, only the coronary artery study should be reported. Coronary CTA without heart structure exam is reported with 0146T or 0147T.

Missed CCTA heart function studies. When heart function evaluation is performed as part of the CCTA exam, add-on code 0151T can be reported with the CCTA exam code. The definition of 0151T mentions left and right ventricular function, ejection fraction, and segmental wall motion. However, these are simply examples of the type of information that might be obtained from a function study. It is not necessary to document all of these elements to report 0151T.

Billing for Doppler echocardiograms without supporting documentation. Most echocardiograms include Doppler wave form (93320–93321) and color flow (93325) studies. However, these add-on codes cannot be reported unless the Doppler exams were performed and documented. The physician’s interpretive report should ideally include separate paragraphs for wave form and color flow findings. And the Doppler codes should never be assigned automatically. Some facilities have their billing software set up to generate Doppler codes every time an echocardiogram charge is entered. This is a risky practice, as the facility may submit charges for studies that were not performed. 

Reporting a noninvasive physiologic study code for ankle-brachial index (ABI) only. The CPT definition of code 93922 mentions the ABI. However, most Medicare contractors feel that performance of the ABI is part of the treating physician’s evaluation and management service and does not warrant reporting code 93922 unless it is part of a battery of noninvasive physiologic tests. Be sure to check your payers’ published policies before reporting 93922 for an ABI done as a stand-alone test.

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